Wednesday, March 31, 2021

For Smokers With Schizophrenia: The JUUL in the Crown


The vast majority of people with mental illness also smoke – a lot.  In fact smoking, which delivers to tortured brains the soothing drug nicotine, is considered by many sufferers, and their doctors, as not optional.

More than 60 percent of schizophrenia patients are current smokers (here), but hope may be found in a small open-label Italian clinical trial, reported by Pasquale Caponnetto at the University of Catania and his colleagues.

Caponnetto et al. recruited 40 people with schizophrenia who did not intend to reduce or quit smoking; they were given JUUL e-cigarettes and pods for 12 weeks.  Caponnetto found that 16 subjects had quit smoking over that period, and 21 others had reduced their cigarette consumption from a median of 25 before the trial, to 10.  At the final six-month follow-up visit, when all participants had been purchasing their own tobacco products for three months, 14 had quit smoking.

This study demonstrates that e-cigarettes can be an aid to cessation or reduced consumption for people with schizophrenia who don’t intend to give cigarettes up.  There is one caveat.

Caponnetto used full-strength JUUL pods – also sold in the U.S. – which contain 59 milligrams of nicotine per milliliter of e-liquid.  The researchers probably obtained special permission from regulatory authorities as the European Union limits e-liquids to only 20 mg of nicotine per ml.  It is likely that smokers with mental illness require higher doses of nicotine in cigarette substitutes.

I am reminded of a short article published in the American Journal of Psychiatry in 2005 (reference here):

“Ms. A, a 52-year-old woman with schizoaffective disorder, bipolar type, started smoking shortly after her first psychotic episode at age 19 and, on average, smoked about 1½ packs per day for 33 years. She had attempted to quit using pharmacotherapy, nicotine gum, or patches in combination with cessation classes. Both gum and patch treatments were ineffective since they did not control her craving for cigarettes.

“Her motivation to quit was strong because of the sequelae of smoking: bronchitis, isolation from others, and destabilization of her psychiatric illness from frequently awakening to smoke. Her brother with a bipolar disorder had experienced severe burns over most of his body and died secondary to a fire caused by his smoking. For her, smoking had become a constant reminder of his suffering, which led to nightmares and further isolation. She was afraid to jeopardize the health and safety of others.

“One year ago, she was cross-titrated over a 1-week period to oral pouches. Since that time, she has not resumed smoking, and her psychiatric and medical symptoms have stabilized. Before her cessation of smoking, she lived an isolated existence. Now she resides with and cares for her parents. For Ms. A, ceasing to smoke was a life-changing event.”

Doctors in 2005 successfully switched a patient with severe mental problems from cigarettes to smokeless tobacco, citing two of my studies (here and here) as the scientific basis for their humane and “life-changing” guidance.   

Now, doctors in Italy have produced life changing evidence that patients with schizophrenia can successfully switch to JUUL.





Wednesday, March 24, 2021

A World-Class Case of Corporate Self-Cannibalization May Save Millions of Lives


Heat-not-burn (HNB) tobacco products – mainly IQOS from Philip Morris (PMI) – are eroding cigarette sales in Japan, as I recently noted.  Prevalence estimates from the Japanese Health and Nutrition Survey confirm the consumption numbers. 

Because the Japanese survey only began tracking new products in 2018, no trend can yet be discerned, but HNB product use is impressive, as shown in the chart at left.  Depending on how dual users are counted, HNB accounted for 20 to 27 percent of all tobacco use in 2019.   

The highly credible Japanese Health and Nutrition Survey is the world’s oldest nutrition survey, implemented by Allied Forces after World War II.  Participants include adults age 20+ years; questions on smoking and HNB use are included in the lifestyle section. 

The HNB-driven Japanese harm reduction miracle has been ignored by most of the world, but Motley Fool just published an intriguing article, “Is It Time to Stop Thinking of Philip Morris International as a Cigarette Company?”

The answer is a resounding “Yes!”

There are two standout quotes in the article.

“Philip Morris' annual report shows that cigarette shipment volumes last year tumbled over 11%, with its most important brand Marlboro, which accounts for 37% of all cigarette shipments, down by a like amount.”

PMI risked its core cigarette business when the company launched the multi-year, multi-billion-dollar IQOS research and development effort.  Five years ago, it rolled the dice again when it marketed the products in Japan.  Leadership had no guarantee that IQOS would preferentially erode only other companies’ cigarette sales.  This may end up as a world-class example of self-cannibalization that ultimately saves millions of lives that would otherwise be cut short by smoking.  

“Philip Morris generated $6.8 billion in revenue last year from IQOS, or almost 25% of its total $28.7 billion in net revenue. [PMI CEO Andre] Calantzopoulos says if you just look at the three regions where IQOS is most prevalent -- Asia, Eastern Europe, and the European Union -- it represents 35% of the total.”

Naysayers have dismissed the Japanese miracle because there is no e-cigarette/vapor market there.  However, there is no doubt about the success of IQOS across 67 countries around the world.  IQOS might now find similar public health success in the U.S.  As Altria broadens distribution here, tobacco prohibitionists should give smoke-free tobacco products the opportunity to cancel smoking and advance public health.




Tuesday, March 16, 2021

Bloomberg Tobacco Article Misleads on Nicotine Effects

In an article published on March 4, Bloomberg reporter Tiffany Kary quotes from a February 25 letter sent to the FDA from Paige Magness, tobacco manufacturer Altria’s senior vice president for regulatory affairs. 

Per the article, “Altria asked the FDA to tackle misperceptions about nicotine as part of a proposed $100 million advertising campaign to reduce the harm caused by tobacco…three-fourths of U.S. adults incorrectly believe[e] nicotine causes cancer, Altria said in the communication, citing government research.”

While National Cancer Institute survey data show that only 25% of Americans correctly believe that nicotine does not cause cancer, Bloomberg erroneously asserts “it’s been known for years that nicotine isn’t the direct cause of many of smoking’s ills.”

The article continues, “The drug has even been touted as a way to ease tension and sharpen the mind,” before noting that it is “the ingredient that addicts people to tobacco products, and it has risks, including possibly making people more susceptible to abusing opioids.”

“Tout” is a derogatory term meaning to describe or advertise boastfully.  Given that nicotine conveys many proven benefits (here, here), touting is not required.  Still, Bloomberg irresponsibly and inaccurately paints it as a gateway to hard drugs.

Altria is not wrong to ask the FDA to combat misinformation about nicotine and tobacco, but the agency is unlikely to act on their request.  FDA officials have made their position clear, saying, in essence, “We will continue to tell Americans that all nicotine/tobacco products are dangerous.  Any manufacturers’ claims to the contrary about their products must be approved by us first.”

Bloomberg says the agency “does have the budget and marketing chops to reach the masses through its public education campaigns. But the agency uses much of those resources on targeting the health risks of products made by the likes of Altria. Its recent ‘Real Cost’ ads say oral tobacco can cause mouth cancer [which is not true, according to government research here], tooth loss [totally bogus, here], brown teeth and jaw pain [also caused by coffee and chewing gum], while ‘most vapes contain seriously addictive levels of nicotine.’” 

In addition to filling smokers’ brains with misinformation, the FDA’s “Real Cost” campaign costs taxpayers real money.  In a commentary published last year in the American Journal of Public Health, I commented that “The [second] largest FDA Center for Tobacco Products budget item ($159.5 million, or 22%) supports public education campaigns and communications to ‘reduce tobacco use’ and tell ‘target audiences’ about the ‘harms of tobacco product use.’ (Original Reference 6)  In this category, ‘The Real Cost’ Youth E-Cigarette Prevention Campaign ( ) shows e-cigarettes invading adolescent bodies as worms and a magician converting e-cigarettes into combustible cigarettes. The FDA has acknowledged, apparently without concern, that the campaign convinces adult smokers that e-cigarettes are equally or more harmful than cigarettes, thus suppressing quitting. (Reference 7).”

Attempting to lend credence to the story, Bloomberg quotes Eric Lindblom, a lawyer who has worked for the FDA and for the prohibitionist Campaign for Tobacco-Free Kids.  Offering the pseudo-revelation that “Nicotine isn’t benign,” Lindblom opines that nicotine “can interfere with brain development [a documented fallacy] and birth outcomes” and closes with a non sequitur: “It’s an agricultural poison in large doses.”

What is the relevance of large-dose agricultural applications to smokers, dippers and vapers?  Absolutely zero, as with the value of the cited Bloomberg hit piece.